Incomplete Longitudinal Ventricular Septal Fracture After Blunt Chest Trauma
A currently asymptomatic 31-year-old man was referred for recent atypical short stabbing chest discomfort occurring at rest. One month earlier, he had complained of a prolonged chest pain episode lasting ≈1 day, temporally related to the use of inhaled cocaine, for which he did not seek medical consultation. He had smoked half a pack of cigarettes a day for 15 years and suffered 2 remote episodes of blunt chest trauma. The first occurred at 12 years of age when he was in a low-velocity automobile accident as a passenger; the second occurred at 18 years of age when he was struck violently across the chest during a fight. Physical examination was unremarkable, but ECG (Figure 1) showed left-axis deviation with complete left bundle-branch block and primary repolarization anomalies, prompting an echocardiogram and chest x-ray (Figure 2). Chest x-ray revealed no sternal or rib fractures with normal pulmonary vascular markings.
The echocardiogram (Figure 3) revealed a longitudinal slit within the interventricular septum, originating from the left ventricular side of the basal inferior interventricular septum with preserved septal motion and thickening with color flow passage within but not to the right ventricle. Gadolinium-enhanced magnetic resonance imaging was performed, confirming the echocardiographic appearance by gradient echo in steady-state of free precession (Figure 4) with no evidence of interventricular shunt, no hyperintensity by T1, or no hypointensity by fat-saturated (SPIR) T1-weighted fast-spin echo to suggest fatty replacement or of late gadolinium enhancement to suggest prior myocardial infarction or fibrosis (Figure 5). The absence of fatty replacement, scar, or fibrosis made the diagnosis of cocaine abuse–related infarction with ensuing rupture less likely than a posttraumatic incomplete septal fracture. The patient has thus far declined surgical repair.
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